Original ArticleSurgical Revascularization for the Treatment of Complex Anterior Cerebral Artery Aneurysms: Experience and Illustrative Review
Introduction
The rapid development of endovascular therapy has contributed to improved treatment outcomes for cerebral aneurysms; however, it has also decreased opportunities for neurosurgeons to gather surgical experience by encountering challenging cases. More than ever, neurosurgeons, especially beginners, learn of the procedures and technicalities of surgery through reading related texts and watching videos of surgical procedures. With this in mind, it is important that complex surgical procedures be readily available in the form of text and/or video for therapeutic and educational purposes.
Intricate surgical procedures are required to treat complex anterior cerebral artery (ACA) aneurysms. Because complex aneurysms located on the ACA are rare and cannot be treated by simple clipping or coiling, they are difficult to manage. These aneurysms may be large or immense in size, fusiform or serpentine in shape, or of a dissected nature; branches may arise from the aneurysms themselves; and there may be a thrombus into the sac, atherosclerosis, or calcification of the aneurysm wall.1, 2 In these situations, it may be necessary to secure distal flow of the aneurysm through revascularization using a bypass technique; however, owing to the rarity of these aneurysms, there are only a few case series of complicated aneurysms located on the ACA.
A few years ago, multiple authors compiled available information on treatment of complex ACA aneurysms based on careful analysis of their own experiences and all previously published cases.3, 4 Each case was specifically classified as a precommunicating, communicating, or postcommunicating segment aneurysm, and this was accompanied by a description of each revascularization method. However, descriptions can be hard to follow, especially for inexperienced neurovascular surgeons. Taking this into account, an illustrative analysis of each method may aid in comprehension and benefit the potential applications of these methods. We present specific and tailored strategies for the surgical treatment of complex ACA aneurysms based on our personal experience and an overview of the available literature. Our purpose was to suggest possible treatment options for each pathologic condition, accompanied by simplified illustrations to aid understanding and future application of the available treatment options.
Section snippets
Materials and Methods
The Institutional Review Board of Kyung Hee University Hospital approved this study. The requirement to obtain informed consent was waived because of the retrospective study design. From April 2011 to February 2017, 93 surgical cases of ACA aneurysm, 84 of which were anterior communicating artery (ACoA) aneurysms, were identified at our institution. Among all cases, only 5 (5.4%) required revascularization for treatment. We retrospectively reviewed the medical and surgical records of these
Results
The 5 unique cases of complex ACA aneurysms treated with revascularization techniques included 1 A1 aneurysm, 1 communicating aneurysm, 1 A2 aneurysm, and 2 A3 aneurysms.5 A combined pterional and basal interhemispheric approach for craniotomy was performed for A1, communicating, and A2 aneurysms (the pterional route was not used for the A2 aneurysm). Superior sinus ligation and falx cerebri intersection were performed for these 3 cases. Falx resection and reflection of the inferior part were
Complex A1 Aneurysm
If the A1 needs to be trapped for the treatment of a complex A1 aneurysm, but the flow across the ACoA is not guaranteed, revascularization is needed for distal ACA flow (Figure 4). In case 1, A3-A3 side-to-side anastomosis via an interhemispheric approach was followed by aneurysm trapping via a pterional approach because the contralateral A1 was thick enough to supply distal flow for both ACAs, and anastomosis between both ACAs could supply both ACA territories following unilateral A1
Conclusions
Complex ACA aneurysms are both rare and difficult to treat. In this series, complex ACA aneurysms were successfully treated with revascularization using an ACA-ACA side-to-side bypass technique Treatment strategies should be carefully tailored to individual cases, with consideration of variations in the anatomy and pathology of individual patients. Thorough preparation with knowledge and practice is crucial for successful treatment of this rare but potentially fatal condition.
Acknowledgments
We thank Joon Young Lee, a student at Seoul International School, for his assistance in reviewing and editing our article. His work primarily consisted of providing insight into English nuances and creating a more coherent and understandable article for readers.
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2022, World NeurosurgeryCitation Excerpt :A combined treatment approach was used in a few studies: microsurgical (clipping or bypass) and endovascular (embolization or proximal arterial occlusion).19 Besides, bypass procedures are often performed by different investigators.13-15,19 As mentioned earlier, surgery of large and giant ACA aneurysms is associated with a high ischemic complication rate, which comprised 25.9% in our series and is comparable with data of other studies (9.1%–28.6%).
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2018, World NeurosurgeryCitation Excerpt :After wide dissection of the interhemispheric fissure to expose the ACA territory and corpus callosum, both the donor and recipient ACA branches are placed under temporary occlusion and then opened to allow STS anastomosis to be performed (Figure 1).40,48 Securing a wider surgical field is required for successful revascularization because the ACA territory is more complicated than that of the other anatomic sites because of the deep and narrow operative field in the interhemispheric fissure.2,9,47,50 Intersecting the falx cerebri, followed by ligation of the superior sagittal sinus, could be performed to create a wider and more comfortable surgical field.
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.